Friday
Jul182014

All Things to All People Isn't Working

By Kim Bellard, July 18, 2014

When it comes to hospitals, we may need to paraphrase Lincoln: they can treat all of the people some of the time, and some of the people all the time, but they can't -- or, rather, they shouldn't -- try to treat all of the people all of the time.

US News & World Report just released their annual "Best Hospitals" rankings.  They evaluated nearly 5,000 hospitals against a detailed methodology

What struck me was that, out of those nearly 5,000 hospitals, only 144 scored a national ranking in even one specialty.  None -- I repeat that, none -- ranked in all 16 specialties.  Only Boston, Los Angeles, and New York had more than one Honor Roll hospital.  Several states have no hospital with a national ranking in any specialty.

There's a lesson there.

A few days ago Clayton Christensen, the Harvard-based guru of "disruptive innovation," told Forbes that the U.S. health industry is "sick and getting sicker."  He offered several suggestions for what he thinks need to change, but I want to pick one in particular, his emphasis on cutting administrative waste.  

It is not unusual to cite administrative waste as a problem in our health care system, but Christensen comes at it from a different angle.  As he said:

An increasing proportion of [health care] cost is spent on administrative and overhead activities that are not productive in any way.  They exist because we assume every hospital should be able to do everything for everybody. But that’s not possible if we want quality and efficiency. Overhead creep is the result.


Toby Cosgrove, the CEO of The Cleveland Clinic, gets it as well (or at least, says the right things).  As he recently said at the Aspen Ideas Festival: "What we need to understand is that not all hospitals can be all things to all people."

Cosgrove noted The Cleveland Clinic's expertise in cardiothoracic surgery, done on a scale that he believes results in care that is cost-effective and of high quality.  They draw patients for these services not just from their metro area, their region, or even just the U.S., but also internationally.  He wants to see a future where we get patients to the right physicians, rather than trying to have expertise available everywhere.

Given the solid data on the importance of volume/experience, then, why are each of my local hospitals trying to make themselves the leader in, say, open heart surgery?  Or in cancer, neurology, or sports medicine for that matter? 

Somehow it is hard for me to believe they've got my interests -- the patient's interests -- as their top priority.  

Becker's Hospital Review recently hosted an Executive Roundtable on affiliation, and I was struck by a comment one of the hospital CEOs made:

There are too many tertiary facilities' values are not aligned with rural hospitals' values: Their goal is to pull patients out of smaller communities, which is not what smaller communities are looking for in an affiliation. Keeping patients close to home is what's important.

Wouldn't you like to think that doing what is best for the patient is what's important? 

The point is, most of us don't live in places where we should be expecting that we're going to get the best care for every condition locally.  Nor should we expect that even the "best" hospital/health system for some conditions are best for other conditions as well.  Who is treating you where for what matters.

This post is an abridged version of the posting in Kim Bellard’s blogsite. Click here to read the full posting

Thursday
Jul102014

State Health Care Prison Spending by the Numbers

by Clive Riddle, July 10, 2014

The State Health Care Spending Project, an initiative of The Pew Charitable Trusts and the John D. and Catherine T. MacArthur Foundation, has been monitoring and analyzing prison healthcare costs for some time, and Pew has just released a new 32-page report: State Prison Health Care Spending: An Examination.

This is on the heels of their report Managing Prison Health Care Spending first released last October, which covered the period of 2001 – 2008, and found that spending sharply increased in most states during that time period. The new report analyzes spending from 2007 – 2011 and found “state spending on prisoner health care increased from fiscal years 2007 to 2011, but it is trending downward from its peak in 2009.”

The new report concludes: “Correctional health care spending poses a fiscal challenge to state lawmakers, though evidence indicates that spending peaked at the end of the last decade. The situation posed by these expenses may be particularly acute in states where older inmates represent a relatively large proportion of the prison population. Corrections officials will be better positioned to manage their systems effectively with access to rigorous, disaggregated spending and health outcomes data that can be used to identify cost drivers and to evaluate the value and impact of cost-containment initiatives.”

Here’s a compilation of various analysis and findings from the new report, by the numbers:

4 key variable characteristics that affect delivery of health care and increase costs include: (A) Prison population trend; (B)  Older inmates, greater expense; (C) Prevalence of disease and mental illness. And (D) Location and inmate transportation.

4 strategies being used to manage costs are: (A) use of telehealth technologies; (B) outsourcing of prison health care, (C) enrollment of prisoners in Medicaid, and (D) appropriately paroling older and/or ill inmates.

37% of health care spending was on general medical care (20% was on hospitalizations; 14% on pharmaceuticals; 14% on mental health; 5% on substance abuse)

39 States saw per-inmate health care spending rise from fiscal 2007-2011, with a median growth of 10%.

41 States experienced growth in their correctional health care spending from fiscal 2007-2011, with a median increase of 13%.

34 States saw their total correctional health care spending peak before fiscal 2011

40 Of 42 states surveyed experienced a rise in the share of older inmates from fiscal 2007-2011

204% increase in the number of state and federal prisoners age 55 and older

from 1999–2012

$441 million - The amount of California’s decrease in spending from fiscal 2009 to 2011 accounting for most of the national decline of half a billion dollars during that time

$7.7 billion total prison health care spending in fiscal 2011

$8.2 billion total prison health care spending in fiscal 2009

Wednesday
Jul092014

One in 5 million Americans now covered by Medicaid

By Claire Thayer, July 7, 2014

The Affordable Care Act (ACA) has had a huge impact on Medicaid enrollment and spending since the expansion of Medicaid eligibility to include almost all adults with incomes at or below 138% of the federal poverty level effective January 1, 2014. The Kaiser Family Foundation recently released, Medicaid Moving Forward, a concise fact sheet summarizing current enrollment, spending and other trends for the Medicaid program.  Lots of data is packed into this fact sheet, here are a few of the important highlights:

Who Does Medicaid Cover?

  • Over 66 million Americans now receive their health coverage through the Medicaid

  • Medicaid and Children’s Health Insurance Program (CHIP) cover more than 1 in every 3 children

  • In June 2013, over 28 million children were enrolled in Medicaid and 5.7 million were enrolled in CHIP

  • The ACA expanded Medicaid to nearly all adults under age 65 with income at or below 138% FPL, effective January 1, 2014.

  • As of June 2014, 27 states, including DC, were expanding Medicaid, three states were actively debating the issue, and 21 states were not moving forward

What does Medicaid Cover?

  • inpatient and outpatient hospital services;

  • physician, midwife, and nurse practitioner services;

  • early and periodic screening, diagnosis, and treatment (EPSDT) for children up to age 21;

  • laboratory and x-ray services;

  • family planning services and supplies;

  • federally qualified health center (FQHC) and rural health clinic (RHC) services;

  • freestanding birth center services (added by ACA);

  • nursing facility (NF) services for individuals age 21+;

  • home health services for individuals entitled to NF care;

  • tobacco cessation counseling and pharmacotherapy for pregnant women (added by ACA);

  • non-emergency transportation to medical care

How do Medicaid Beneficiaries Get Care?

  • Most Medicaid beneficiaries obtain care from private office-based physicians & other health professionals.

  • Safety-net health centers and hospitals also play a major role in serving the Medicaid population.

  • Over half of Medicaid beneficiaries nationally, mostly, children and parents, are enrolled in comprehensive managed care organizations (MCO) that contract with states on a capitation, or risk, basis to deliver Medicaid services

  • A smaller but still significant number of beneficiaries are enrolled in Primary Care Case Management (PCCM) programs

How much does Medicaid cost and how is it financed?

  • In FY 2012, Medicaid spending on services totaled about $415 billion

  • Administrative costs accounted for 5% of overall program spending.

  • Two-thirds of all spending on services was attributable to acute care

  • 30% of all spending on services was associated with long-term care.

  • Supplemental payments to hospitals that serve a disproportionate share of Medicaid and uninsured patients, known as “DSH,” accounted for about 4% of spending

  • Medicaid payments for Medicare premiums and cost-sharing on behalf of dual eligible beneficiaries totaled 3.5%.

Source: Medicaid Moving Forward, The Henry J. Kaiser Family Foundation, June 17, 2014.

Additional Issue Briefs that might be of interest:

Katherine Young and Lisa Clemans-Cope and Emily Lawton and John Holahan, Medicaid Spending Growth in the Great Recession and Its Aftermath, FY 2007-2012, The Henry J. Kaiser Family Foundation, Issue Brief, July 3, 2014.

Samantha Artiga and Robin Rudowitz, Medicaid Enrollment Under the Affordable Care Act: Understanding the Numbers, The Henry J. Kaiser Family Foundation, Issue Brief, January 29, 2014.

 

Monday
Jun302014

Marketplace: 57% of New Enrollees Were Uninsured Before Signing Up

By Cyndy Nayer, July 1, 2014

Kaiser Family Foundation--KFF-- issued a new summary on the enrollees in the insurance marketplaces, which MCOL has summarized.  In short, most of the enrollees in the #ACA were uninsured before the rollout, and most of the 57% had been without coverage for 2 years.

The chronicles of the value-based movement have shown that when costs for acquisition (copays and co-insurance, often called out-of-pocket costs) are reduced, more people become engaged and adherent in their health care.  This is important in the management of chronic disease.

But if we are determined to build a culture of health in the US, then the engagement and adherence of newly-insured to prevention strategies as well as lifestyle change will be critical. The efforts in incentive-based designs (value-based for beneficiaries and for service providers, such as physicians, health plans, care coordinators, and more) must retool to encourage 24/7 improvement.  Focusing on appropriate choices whenever possible, adding 10-minute exercise breaks, and identifying friends and relatives who encourage and join in the exercise, screenings, and healthy foods are goals that we can all achieve.

Thank you to MCOL for its continued data vigilance so that, together, we can build the healthiest US.  [image courtesy of KFF]

Breakdown of Marketplace enrollees prior to purchasing current plan;

Covered by a different non-group plan 16%
Covered by Medicaid/other public program 9%
Covered by an employer/COBRA 14%
Other/Don't Know/Refused 4%
Uninsured 57%

Source: Kaiser Family Foundation

Wednesday
Jun252014

May I Speak to the Doctor's Computer? 

By Kim Bellard, June 25, 2014

There's a new provocative study in Computers in Human Behavior that suggests we may be more likely to tell the truth about personal matters, such as health problems or medical history, when talking to a virtual human instead of to an actual human.  I'm not sure if these findings threaten to set back the patient-physician relationship 10,000 years, or promise to advance it fifty years.

The article -- It's Only a Computer, by Lucas, Gratch, King, and Morency -- tested participants' willingness to disclose information to a "virtual human" on a computer screen.  When the participants believed the virtual human was fully automated instead of being controlled by a human, they reported lower fear of self-disclosure, were less likely to shade the truth in order to create a good impression ("impression management"), and were rated as being more willing to disclose information.  The key to the behavior was their belief that no human was involved, whether or not a human was actually acting behind the scenes.

The virtual human idea is not pie-in-the-sky, good only for research studies.  Versions of it are already being tested, such as by Sense.ly, whose digital health avatar was profiled by MIT Technology Review a year ago.  It captures patient information via an avatar, which can respond to patient statements or data and can even answer questions.  

Clearly, we're entering a new world.

The kind of artificial intelligence that might power these avatars/virtual humans can also be used to assist physicians instead of competing with them.  IBM, of course, has been touting Watson in health care for several years now.  As Wired recently reported, there are a number of AI efforts out there to assist physicians. 

Wired also notes that companies are trying to keep their products viewed as offering recommendations instead of making decisions, which would push them over into FDA approval and regulation.  We probably will get there, but that step will be a big gulp.

Some experts believe people will improve their health behaviors -- e.g., get more exercise or lose more weight -- if they know they are being monitored.  Others fear people will end up forgetting about their trackers and will slide back to their previous behaviors. 

The plethora of tracking devices poses issues not only with the sheer volume of data generated, but also with integrating the disparate data from multiple operating systems into a unified record. 

The idea that health information is only collected at a medical office or lab, and that patients should wait to act on it until a human can talk to them, is simply no longer viable.  The data are increasingly going to be available 24/7, and when it means something important there have to be mechanisms to act upon it in real-time.   Maybe that is through alerts to physicians, who then initiate contact with patients, or maybe the wearable ecosystem can trigger its own alerts and advise the user what is going on using avatars and other automated mechanisms.

A recent op-ed by Dominic Basulto in The Washington Post stated that "Google and Apple want to be your doctor, and that's a good thing."  Mr. Basulto concluded:

Companies like Apple and Google can help to break down the notion that health has to be something offered by a monolithic company with a confusing set of rules and terms. It might just be the case that mobile health care facilitated by wearable tech will turn out to be better than traditional doctors.

I think it is a stretch to say that mobile health will be "better" than traditional doctors, but I think these and other technological options can certainly radically change when, why and where people need to see physicians or other health care professionals.  And that's good.

This post is an abridged version of the posting in Kim Bellard’s blogsite. Click here to read the full posting